Ce travail décrit les trajectoires des adolescents qui sont amenés à être suivis en psychiatrie parce qu'ils refusent d'aller à l'école en France. Il se propose ainsi d’employer une démarche sociologique de théorie ancrée (Grounded Theory) afin de répondre à une question de santé publique. En 1991, on estimait que les enfants et adolescents refusant d'aller à l'école représentaient 5% des consultations de pédopsychiatrie en France. Depuis 25 ans, il demeure pourtant difficile de quantifier ce phénomène et son évolution, notamment parce que le refus scolaire ne correspond à aucune catégorie de maladie mentale. L'enjeu sociétal et économique est toutefois considérable. Les associations de parents alertent sur le coût élevé de la déscolarisation, la 'phobie scolaire' rencontre un écho médiatique constant, et les jeunes qui achèvent leurs études sans obtenir de diplôme ont un taux de chômage supérieur à la moyenne pour leur tranche d'âge. De plus, une littérature psychiatrique internationale considérable sur le refus scolaire s’adosse à de nombreuses institutions de soin dédiées à la rescolarisation (consultations et hôpitaux de jours) et de manifestations professionnelles à ce sujet. Dans un contexte de contraintes budgétaires du sanitaire et de crise du système éducatif français, la gestion par le champ médical du refus scolaire pose question. Premièrement, une analyse socio-historique de la littérature médicale internationale entre 1941 et 2018 décrit comment le problème du « refus scolaire » s’est développé dans le discours scientifique selon les deux courants distincts de la phobie scolaire (school phobia) et du refus scolaire (school refusal) ; et tend actuellement à s’élargir vers une problématisation médicale de toute absence scolaire. La deuxième et la troisième partie de ce travail explorent les processus décisionnels qui sous-tendent la médicalisation du refus scolaire à l’échelle individuelle. En effet, le diagnostic psychiatrique intervient relativement tard, à l’issue d’une carrière débutée au sein de l’institution scolaire et de la famille. Comment un jeune en vient-il à être désigné par la catégorie de 'phobie scolaire'? Cette approche interactionniste se fonde sur plus de 100 entretiens réalisés auprès de familles et de professionnels de l’école et analyse le travail produit par le jeune et par les acteurs qui l’entourent. On décrit comment les professionnels de l’école repèrent et qualifient ses difficultés de fonctionnement scolaire. Quatre styles de gestion du problème émergent au sein de l’école, selon le degré d’extériorisation du problème hors du champ scolaire, l’usage des pratiques de care et les modes relationnels avec les autres acteurs. Une analyse dite des « carrières » retrace la trajectoire d’adolescents déscolarisés, de l'école à l'hôpital, en partant du récit des jeunes et de leurs parents. Si les enquêtés présentent le refus scolaire comme une prise de décision brutale, celle-ci vient interrompre un processus de longue durée notamment caractérisé par un épuisement lié au travail de représentation de soi en société. Après la décision de refus scolaire, sont analysés le récit de la transformation de soi, le remaniement des relations aux autres (parents, camarades, enseignants, soignants), la déconstruction et la construction de certaines modalités de socialisation. / School refusal is an increasingly common motive for consultation in child psychiatry. According to the psychiatrists, situations leading to school refusal are extremely diverse, from anxiety feelings in the classroom to truancy, and may lead children to miss school occasionally or to give up their studies. This sociological study, uses the grounded theory to describe the career of teenagers who receive psychiatric care in France because they refuse to go to school. More than 100 in-depth interviews with teenagers, parents and school professionals allow to describe their careers from the school to the psychiatric care. First, we provide a socio-history of the medicalization of school absenteeism through the construction of medical categories (school phobia, school refusal, school attendance problems), based on a review of the international psychiatric literature from 1941 to 2018. Second, teachers discourse on school refusal, their daily management of student who refuse school and their involvement in the medicalization of the absenteeism of some pupils is analyzed. Four styles of management are described among school professionals. Third, the narratives of teenagers and of their parents are analyzed. If school refusal appears as an immediate shift, it answers to a process of long duration. For some students, struggling to attend school from day to day required a consuming work: the presentation of self in public places and emotional work towards peers. After refusing school, students ‘illness’ narratives describe their career in deconstructing and reconstructing their socialization and self.

Le handicap est multifactoriel. Toutes ses composantes sont potentiellement sources d’obstacles et de désavantages. L’originalité de cette thèse est de tenir compte de la complexité de définition du handicap dans l’analyse du recours aux soins de santé primaires. L’objectif ultime des soins de santé primaires est une meilleure santé pour tous, passant par la réduction des exclusions et des inégalités sociales d’accès au système santé. Nous appréhendons le handicap de différentes manières jusqu’à intégrer les trois dimensions d’« une situation de handicap » (dimension fonctionnelle, dimension environnementale, et participation sociale) dans un même modèle explicatif. D’abord, nous analysons la dimension fonctionnelle en considérant les personnes handicapées comme physiquement limitées. Puis, nous investiguons la dimension environnementale par une étude chez les adultes vivant en institution. Enfin, nous adoptons une vision globale du handicap en intégrant simultanément toutes les dimensions par la mesure de capabilités latentes. Le modèle estimé s’approche d’une comparabilité inter-individus révélant, toutes choses égales par ailleurs, les niveaux sur lesquels agir pour pallier les inégalités. Les analyses suggèrent qu’un environnement favorable, sociétal et/ou socioéconomique, pourrait compenser les effets négatifs des limitations et des restrictions cognitives et physiques. Nous concluons sur plusieurs voies possibles afin d’améliorer le recours aux soins primaires : agir sur la dimension environnementale et sur la participation sociale. / Disability is multifactorial. All its components are potential sources of barriers and disadvantages. The originality of this thesis is to take into account the complexity of disability definition to analyze the use of primary health care. The ultimate goal of primary health care is better health for all, reducing exclusion and social inequalities in access to the health care system. We approach disability in different ways, ending with a model that includes the three dimensions of a “disability situation” (functional dimension, environmental dimension and social participation). First we analyze the functional dimension considering people with disabilities as physically limited. Then, we investigate the environmental dimension through analysis among adults living in institutions. Finally, we adopt a global vision of disability that integrates all the dimensions simultaneously through the measures of latent capabilities. The estimated model approximates a fundamental inter-individual comparability and reveals all things being equal, the levels on which to act to overcome inequalities. The analyses suggest that favorable environment, societal and/or socioeconomic could offset the negative impact of the limitations and cognitive and physical restrictions. We conclude on several possible waysto improve the use of primary care: acting on the environmental dimension and acting on social participation.

Cette thèse porte sur les difficultés d'accès aux soins dentaires dans le marché français semi-régulé. L'analyse cible la barrière financière d'accès aux soins dentaires et ainsi le rôle et le mécanisme de fixation des prix. La première partie permet de contextualiser la délivrance des soins dentaires en France et montre que la profession de chirurgiens-dentistes est particulièrement isolée dans le domaine sanitaire français. L'objet de la seconde partie est d'identifier les déterminants de l'accès aux soins dentaires. Nous montrons que le programme de prévention pour les enfants M'T'dents, entièrement gratuit, n'était utilisé que par les ménages les plus aisés et touchait peu les ménages défavorisés qui en ont le plus besoin. L'importance du support social dans l'accès aux soins est aussi affirmée dans notre seconde étude empirique. L'accès primaire aux soins dentaires des adultes présente la principale barrière d'accès. Une fois cette difficulté surmontée, les patients engagent le plus souvent les traitements suivants nécessaires, avec des niveaux de dépenses qui peuvent être importants même pour les moins aisés. À la suite de ces résultats, nous nous sommes intéressés spécifiquement au rôle du prix. Nous avons montré que plus le prix des prothèses dentaires était élevé, plus le renoncement à ces soins pour raisons financières était important. D'après nos travaux, l'intensité de la concurrence impacte négativement la fixation des prix contrairement à la solvabilité de la demande. Les prix entre concurrents sont aussi des compléments stratégiques. Ce sont autant de facteurs susceptibles d'être régulés pour lutter contre le renoncement aux soins dentaires et les inégalités sociales de santé qui en résultent. / This thesis concerns the difficulties to access dental care in the semi-regulated French market. The analysis targets the financial barrier of access to dental care and so the role and the mechanism of price setting. The first part gives the background of the French dental care delivery and shows that the profession of dental surgeons is particularly isolated in the French sanitary domain. In the second part we identify the decisive factors of the dental care access. We show that the free preventive program for the children Lov'Ur'Teeth was used only by the wealthiest and affected little the most disadvantaged households, which need it much more. The decisive impact of the social support in access to dental care is also a strong result in our second empirical study. The primary access to the dental treatment presents the main barrier of access. When people overcome this difficulty, they mostly continue the ensuing necessary treatments, that could be very expensive. Following these results, we focused in the role of the price. We showed that the more the prosthetic prices are high, the more is the renunciation for these cares. According to our works, the intensity of the competition impacts negatively the price setting, contrary to the demand's solvency. The prices between competitors are also strategic complements. That are many potential factors to be regulated to fight against the dental unmet need and the resulting social health inequalities.

The purpose of this quantitative study was to examine the interaction between parents’ own trauma and their assessment of their child’s functioning and its relationship to the parent’s belief that their child would benefit from mental health care services. The parents’ trauma experience was measured using the Adverse Childhood Experiences (ACEs) questionnaire and Trauma History Questionnaire (THQ), and the child’s functioning was measured using the Columbia Impairment Scale (CIS). It was hypothesized that the higher number of traumas a parent experienced was associated with a weaker relationship between a parent’s assessment of their child’s functional impairment and the likelihood a parent recognizes the benefit of mental health care services for their child. One hundred and eighty-four people participated in this study. Data were analyzed using multiple binary logistic regression, and no significant relationship was found between a parent’s assessment of their child’s functional impairment and that parent’s belief that their child would benefit from mental healthcare services. The parent’s childhood THQ score and age were found to have significant positive relationships with the parent’s belief that their child would benefit from mental healthcare services. The variable found to have the most significant positive relationship with the parent’s belief that their child would benefit from mental healthcare services was an educational or healthcare professional telling the parent that the child would benefit from mental health care services. Clinical implications, limitations, and future directions for research were addressed.

Of the 3.5 million persons infected with chronic HCV in the United States, the African American population is the largest racial group with chronic HCV. Disparities in access to care and treatment involve a complex set of individual, interpersonal, socioeconomic, and environmental factors that influence the course of HCV infection in the African American population, resulting in poorer outcomes and survival. Drawing upon both the theory of reasoned action and the theory of planned behavior, this study was conducted to determine whether the seeking of health care by HCV-positive African Americans and the responses of health care providers to HCV-positive African Americans had improved since 2008 following the introduction of new treatment options, as compared to other HCV-positive racial/ethnic groups, using secondary data analyses with survey datasets from the National Health and Nutrition Examination Survey, 2005-2012. Using chi-square test of difference and logistic regression analyses, the study did not identify a statistically significant relationship between health care seeking behavior and responses from health care providers for HCV-positive African Americans before (2005-2008) and after (2009-2012) the introduction of new treatment options as compared to other HCV-positive racial/ethnic groups. Given the ongoing development of new and improved drugs to treat HCV infection, further research might focus on the HCV-infected population as a whole to ascertain whether differences exist as compared to earlier therapies before 2013. This study may drive social change within the health care community by raising awareness of the risks of HCV infection resulting in less provider bias and the introduction of resources into the African American and underserved communities that will improve outcomes and reduce barriers to care.

Interprofessional education (IPE) is essential for enhancing students’ critical thinking skills and ability to integrate other professionals’ knowledge to ensure mutual respect and shared values for patient-centered care. The needs of medically underserved populations (MUPs) to receive behavioral health and nutritional care integrated with primary care services are significant. This research highlights the data outcomes from six offerings of a graduate IPE course on integrated health care. Funding from a Health Resources and Services Administration (HRSA) Behavioral Health Workforce and Education Training (BHWET) grant provided stipends for graduate social work and school counseling students in their final year of field working with MUPs in integrated care settings. Findings indicate significant increases in integrated care knowledge from pre- to post-course. Students reported appreciating the social justice framework of the course including food security and access to care. Students suggest that the course be required of all, not just stipend recipients. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Behavioral Health Workforce Education and Training Program Grant No. M01HP313900100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

No description available.

Mon mémoire est par article. Mon article a été soumis au Canadian Journal of Public Health et est actuellement en cours de révision. Je n'ai pas encore de réponse et je n'ai pas d'indication précise concernant les délais de traitement. / Contexte : Les soins obstétricaux non respectueux sont un phénomène de plus en plus reconnu partout dans le monde. Ce problème touche particulièrement les personnes appartenant à un groupe marginalisé, telles que les personnes immigrantes. Objectifs : Comparer l'expérience des soins obstétricaux au Québec entre les personnes immigrantes et celles nées au Canada, en identifiant les facteurs influents. Méthodes : Une enquête transversale a été menée auprès de personnes ayant reçu des soins obstétricaux au Québec entre 2016 et 2023. Beaucoup de démarches ont été effectuées en collaboration avec les partenaires du projet pour le recrutement des participants via les médias sociaux, en répondant au questionnaire en ligne entre juillet et décembre 2023. Les expériences de soins obstétricaux, y compris l'autonomie mesurée par l'échelle MADM (Mothers Autonomy in Decision Making Scale) et la maltraitance évaluée par l'indice MIST (Pregnant Persons Experience of Mistreatment by Providers Index), l'accès aux soins et la satisfaction envers le savoir-être du personnel soignant, ont été comparés entre les deux groupes. Résultats : Parmi les 686 participants, 11,2 % étaient des immigrants, dont 69 % ayant un statut permanent et 14,3 % avec un statut temporaire. Aucune différence significative n'a été trouvée dans l'échelle MADM entre les groupes (p = 0,903), mais les immigrants avec un statut temporaire étaient 9,25 fois plus susceptibles d'avoir une faible autonomie comparativement aux personnes nées au Canada (IC à 95% : 0,98 - 75,3, p = 0,044). Selon l'indice MIST, 28,6 % des immigrants ont signalé au moins une forme de maltraitance contre 35,8 % des personnes nées au Canada (p = 0,172). De plus, 9,1 % des immigrants ont payé les soins par des fonds personnels comparativement à 4,4 % des personnes nées au Canada (p = 0,173). La satisfaction à l'égard du savoir-être des professionnels de santé était similaire entre les groupes, mais une faible autonomie diminuait significativement cette satisfaction de 60 % (IC à 95% : 0,02 - 0,09, p < 0,001). Conclusion : L'étude révèle quelques différences dans l'expérience des soins obstétricaux entre les immigrants et les personnes nées au Canada, mettant en lumière les besoins spécifiques des immigrants. / Context: Disrespectful obstetric care is an increasingly recognized phenomenon worldwide. This issue particularly affects individuals belonging to marginalized groups, such as immigrants. Objectives: To compare the experience of obstetric care in Quebec between immigrants and individuals born in Canada, identifying the influencing factors. Methods: A cross-sectional survey was conducted with individuals who received obstetric care in Quebec between 2016 and 2023. Extensive efforts were made in collaboration with project partners to recruit participants via social media, who completed the online questionnaire between July and December 2023. Obstetric care experiences, including autonomy measured by the MADM (Mothers Autonomy in Decision Making Scale), mistreatment evaluated by the MIST (Pregnant Persons Experience of Mistreatment by Providers Index), access to care, and satisfaction with the interpersonal skills of healthcare staff, were compared between the two groups. Results: Among the 686 participants, 11.2% were immigrants, with 69% having permanent status and 14.3% having temporary status. No significant difference was found in the MADM scale between the groups (p = 0.903), but immigrants with temporary status were 9.25 times more likely to have low autonomy (CI: 0.98 - 75.3, p = 0.044). According to the MIST index, 28.6% of immigrants reported at least one form of mistreatment compared to 35.8% of individuals born in Canada (p = 0.172). Additionally, 9.1% of immigrants paid for care out of pocket compared to 4.4% of individuals born in Canada (p = 0.173). Satisfaction with the professionalism of healthcare professionals was similar between the groups, but low autonomy significantly decreased this satisfaction by 60% (CI: 0.02 - 0.09, p < 0.001). Conclusion: The study reveals some differences in the experience of obstetric care between immigrants and individuals born in Canada, highlighting the specific needs of immigrants.

No description available.

The Universal Declaration of Human Rights and Fundamental Freedoms and the International Covenant on Economic, Social and Cultural Rights state that everyone has the right to good health. According to the conventions, the states have obligations to prevent and combat disease, and if necessary, ensure that the conditions for treatment of the disease are appropriate (UDHR 1948, UNCESCR 1966). The broad wording in the conventions on the right to good health includes the right to care of substance use disorders. In the 1960ies the World Health Organization recommended, that people with such disorders should be seen as sick and that the legislation governing such care should be in accordance with special administrative legislations and not criminal legislation. The recommendation indicates WHO:s clear position that persons with substance use disorders primarily should be treated as persons suffering from disease and in need of care, and not primarily as disruptive individuals or criminals who should be disciplined or punished. This applies also to situations when treatment and care cannot be provided on a voluntary basis, but compulsorily. In Swedish context, the most commonly mentioned law in these cases is the social special legislation Law (1988: 870) on care of misusers, special provisions (LVM). Ever since the implementation of LVM in 1982, its legal position as well as application in institutional care has been subject of critical discussions within social work as well as in social science research. Such debate in the Nordic countries has until now mostly been marked by two important limitations. First, most comparisons are restricted to very few countries, e.g. four of the Nordic countries; secondly the notion of involuntary care is often limited to social legislation on compulsory care without taking criminal justice legislation or mental health legislation into account. The present dissertation studies legislations on compulsory commitment to care of persons with substance use problems (CCC), and compares these legislations from a larger number of countries, on global or European levels. This approach makes it possible to explore the great variation in CCC legislation between countries, i.e. type of law (criminal justice, mental health care and social or special legislation),  time limits (maximum duration) as well as levels of ambition, ethical grounds, criteria for admission, and adaption to human and civil rights.  In addition, the comparisons between many countries are used to investigate factors related to different national choices in legislations from country characteristics, e.g. historical and cultural background as well as economic and social conditions, including level and type of welfare distribution. Available datasets from different times permits trend analyses to investigate whether CCC or specific types of such are increasing or decreasing internationally.          Empirical materials: Article I is based on three reports from the WHO on existence of CCC legislation, before the millennium shift, in 90 countries and territories in all populated continents. Articles II and IV are based on own data collection from a survey in 38 European countries. Article III uses a combination of those data and additional information from country reports in scientific and institutional publications in three times of observation during more than 25 years, and including a total of 104 countries. Additional data for Articles I and II are information on various countries' characteristics obtained from different international databases.          Findings based on data from WHO reports at the eve of the millennium show that CCC legislation was very common in the world, since 82 per cent of the 90 countries and territories had such law. Special administrative (“civil”) legislation (mental health or social) was somewhat more prevalent (56 %), but CCC in criminal justice legislation was also frequent and present in half of the countries. The study shows that economically stronger countries in the western world and many of the former communist countries in Eastern Europe, the so-called "first and second worlds" in cold war rhetoric, more often had adapted to the recommendations made by WHO in the 1960ies, with CCC more often regulated in civil legislation. In the so-called "third world" countries, CCC in criminal justice legislation dominated. The new data collection from 38 European countries ten years later confirmed that legislation on CCC is very common, since 74 per cent of the explored countries have some type of legislation. The most common type was now CCC in criminal legislation (45%), although special administrative legislation (mental health or social) was almost equally common (37%). Special administrative legislation on CCC (both acute and rehabilitative), was more common in countries with historic experience of a strong influential temperance movement, and in countries with distribution of health and welfare more directed through the state, while countries with less direct government involvement in distribution of health and welfare and lacking former influence of a strong temperance movement more often had CCC in criminal justice legislation. During all the 25 years period from early 80ies up to 2009, it was more common for countries to have some type of law on CCC than not, although some reduction of CCC legislation is shown, especially during the last decade. But within countries having CCC, more cases are compulsorily committed and for longer time duration. This is related to a global shift from civil CCC to CCC in criminal justice legislation, directly in the opposite direction from what WHO recommended in the 60ies. Changes in CCC legislation are often preceded with national political debate on ethical considerations, and criticisms questioning the efficiency and content of the care provided. Such national debates are frequent with all types of CCC legislation, but ethical considerations seem to be far more common related to special administrative (civil) legislation. National legislations on CCC within Europe should conform to the human and civil rights stipulated in ECHR (1950). There seems, to be some limitations in the procedural rules that should protect persons with misuse or dependence problems from unlawful detentions, regardless type of law. The three types of law differ significantly in terms of criteria for CCC, i.e. the situations in which care may be ensured regardless of consent.        Conclusions: It is more common that societies have legislation on CCC, than not. This applies internationally – in all parts of the world as well as over time, for a period of 25 years, at least. Sweden’s legislative position is not internationally unique; on the contrary, it is quite common. Law on CCC tend to be introduced in times of drug epidemics or when drug-related problems are increasing in a society. Changes in CCC legislation are often preceded by national debates on ethics, content and benefits of such care. These findings here discussed may reflect different concurrent processes. A shift from welfare logic to a moral logic may be understood as more moralization, perhaps due to relative awaking of traditionalism related to religious movements in various parts of the world (Christian, Hindu, Muslim or other). But it may also be understood from more libertarianism that stresses both individual responsibility for one’s welfare and the state´s responsibility to discipline behaviours that inflict negatively on the lives of others. Possibly do these two tendencies work in conjunction to one another. At the same time, however, there is a stronger emphasis on care content within criminal justice CCC, especially in the Anglo-Saxon drug court system. Some shift within Civil CCC is also noticed, i.e. from social to mental health legislation. Thus drug abuse and dependence is increasingly more recognized and managed in the same way as other diseases, i.e. an increased normalization. Since social CCC has been more in focus of research and debates, this may also result in CCC turning into a more hidden praxis, which from ethical perspectives is problematic. The thesis shows that there are examples of focus on humanity and care in all three of the law types, but there are also examples of passive care, sometimes even inhumane and repressive, in all types. Thus, type of law cannot be said to in general correspond to a specific content of care. Although CCC can be delivered in accordance with human and civil rights, there is still a dissatisfying situation concerning the procedural rights that should ensure the misuser his/her rights to freedom from unlawful detention. The possibility to appeal to a higher instance is missing in about 20 percent of European CCC laws, although not differentiating one type of legislation from the others. A clear difference between the three law types concerns criteria that form the basis for who will be provided care according to the laws. This is of major importance for which persons of the needy who will receive care: addicted offenders, out-acting persons or the most vulnerable. The criteria for selecting these relate to the implicit ambitions of CCC – correction, protection, or for support to those in greatest need for care. The question is what ambition a society should have concerning care without consent in case of substance abuse and addiction problems. The trend that CCC according to special administrative legislation is declining and criminal legislation increases in the world should therefore be noticed.     Keywords: Alcohol, drugs, substance misuse, coercive care, compulsory commitment to care, involuntary care, mandatory care, legislation, human and civil rights, comparative analysis, prediction models, and trend analysis / <p>Vid tidpunkten för disputationen var följande delarbeten opublicerade: delarbete 4 inskickat.</p><p>At the time of the doctoral defence the following papers were unpublished: paper 4 submitted.</p>